Bioethics and natural law: an interview with John Keown

Bioethics discourse is often divided into two broad categories: utilitarian perspectives and so-called deontological or Kantian approaches to ethics. An alternative viewpoint that receives far less attention is a natural law perspective on ethics and medicine. The natural law approach emphasizes interests or ends common to all members of humanity, and offers a teleological account of morality and human flourishing.

Professor John Keown of Georgetown University’s Kennedy Institute for Ethics recently co-authored a book on natural law with the late Georgetown Professor Alfonso Gómez-Lobo. The book is entitled Bioethics and the Human Goods: An Introduction to Natural Law Bioethics. The Deputy Editor of BioEdge, Xavier Symons, interviewed Professor Keown about his latest work.

Xavier Symons: What led you to write Bioethics and the Human Goods: An Introduction to Natural Law Bioethics?

John Keown: The book was largely written by my distinguished colleague and friend, the late Professor Alfonso Gómez-Lobo, who held the Ryan Chair in Metaphysics and Moral Philosophy at Georgetown. Before his untimely death at the end of 2011, he had submitted a manuscript to Georgetown University Press. With the kind permission of his widow, and with the approval of the Press, I completed the project, incorporating amendments that he had indicated, in his comments on the referees’ reports, that he wanted to make, and some amendments that I thought appropriate. About a third of the book is material I added to his original manuscript. I thought it important, given the regrettable dearth of introductory books on bioethics from a natural law perspective, that his manuscript should be enlarged, updated and completed

What contribution do you think natural law can make to the field of bioethics?

Natural law has made, and has the potential to make in future, a signal contribution to the ethics of healthcare and to bioethics more broadly conceptualised. Natural law theory could be described as the most enduring and important moral tradition in Western thought, and it has had a profound influence on Western law, professional medical ethics, and culture.

Many laws and codes of ethics are grounded in the natural law articulation of certain fundamental moral principles that should always be respected, regardless of the consequences. For example, in relation to euthanasia, the prohibition on intentionally killing patients, which is still reflected in the law of the vast majority of jurisdictions, and in the ethics of the World Medical Association, is grounded on one such principle: the principle that it is always wrong intentionally to kill a person, even at that person’s request.

Unlike other approaches to bioethics, most notably utilitarianism, natural law theory can offer a coherent account of the intrinsic wrongness of treating patients in certain ways, such as intentionally killing them, lying to them, or exploiting them, however beneficial it might be to others or to society to do so.

Moreover, although utilitarianism and ‘principlism’, in their various forms, are undoubtedly dominant in bioethics education today, it is important for students to realise that there is an alternative ethical tradition, one which makes sense of much of contemporary law and professional ethics, and which offers a radically different approach to bioethical reflection. Indeed, it seems to me that no student can understand bioethics (or, indeed, biomedical law) properly without at least a basic grasp of natural law theory. Without such a grasp, they have at best a partial understanding of the field. I fear that the many students of bioethics who are unfamiliar with the natural law tradition do not even know what they do not know.

Unfortunately, although the literature on bioethics is vast, that literature largely either ignores natural law theory, mentions it only in passing, or misunderstands it. There is, therefore, an important and urgent need for this book, and more books like it.

I have lost count of the number of times I have been asked ‘Could your recommend a clear, introductory book on natural law bioethics, suitable for the college student or the general reader?’ Now, I have a ready answer. Previously, I recommended one or two books like Professor Gómez-Lobo’s Morality and the Human Goods (Georgetown University Press, 2002). However, although that book does touch on a number of bioethical issues (especially abortion and euthanasia), it is more an introduction to natural law ethics rather than natural law bioethics. Still, it would make an excellent companion volume, and I think students would find it valuable to read it before reading Bioethics and the Human Goods.

Professor John Keown

The book mentions ‘basic goods’ and their importance for natural law theory. What are they and why are they so important?

The starting-point for natural law theory is to ask ‘What is the Good Life?’ It rejects standard utilitarian answers, whether in terms of pleasure or the satisfaction of desires, both of which could be used to justify obviously immoral acts. The answer given by natural law theory is that the Good Life is a life which involves true human fulfilment or flourishing. And what is a truly flourishing life? One in which one participates in the goods of life, health, friendship, knowledge, appreciation of art and beauty, work, play and practical reasonableness. (The precise formulation of basic goods may vary depending on which theorist one reads, but the theorists share the same, basic idea.) These goods are ‘basic’ in the sense that they are not merely instrumental goods, but are ends in themselves, worth pursuing for their own sake, and self-evidently so. (Of course, basic goods like health and knowledge can also be instrumentally valuable, but that does not reduce their worth to mere instrumentality. It is, for example, good for us to know about bioethics, or the history of the American Revolution, or one’s own personal history, even if one never uses that knowledge instrumentally.)

The basic goods form an objective basis for natural law ethics, but they need to be supplemented by intermediate moral principles, intermediate between the basic goods and our judgment about the ethics of particular conduct (‘Is it right for me to tell the patient he is fine when I know he is dying?’ ‘Should I allow the patient’s refusal of consent to prevent me from carrying out harmless and potentially ground-breaking research on her while she is anaethetised?’) Much of Professor Gómez-Lobo’s book Morality focused on the key principles of ‘care’ and ‘respect’. In Bioethics he reformulates them in terms of ‘beneficence’ and ‘non-maleficence’. In doing so, he recognises the influential ‘four principles’ approach advocated by Professors Tom Beauchamp and Jim Childress, but he explains how those principles are conceived and applied from a natural law, rather than from a principlist, perspective. He rejected the ‘four principles’ approach on the ground that it failed to give a substantive account of the Good. Without such an account, he argued, it is impossible to judge what truly benefits or harms another.

In your book you suggest that, although natural law theory is compatible with major religious traditions, it is not grounded in religion. Can you explain?

Adherents of the great religions will find much in natural law that resonates with their teachings, such as its insistence that all human beings share a fundamental equality-in-dignity, including the most vulnerable, whether babies, people with profound intellectual disabilities, the comatose, the demented, the suffering and the dying.

For example, natural law theory’s opposition to infanticide (in contrast to its endorsement by leading utilitarians) resonates with the long-standing opposition to infanticide in the Judaeo-Christian tradition (in contrast to its endorsement by the ancient Greeks and Romans). Natural law thinkers reject the ‘dualist’ notion of personhood, in which only some human beings, with certain mental abilities, count as ‘persons’ and others, like babies or elderly folk with severe dementia, do not. Moreover, natural law theory is the philosophical tradition of the Catholic church. Further, my brother Professor Damien Keown has, in his many publications, noted similarities between natural law ethics and Buddhist ethics.

Despite these resonances between natural law theory and teachings of the great religions, however, natural law theory remains a philosophy, not a theology. It traces its origins to pre-Christian Greek thinkers like Aristotle, and is reflected in contemporary human rights documents in what many would describe as our post-Christian world. Anyone can, and many do, adopt natural law’s absolute prohibitions on, say, torture or euthanasia, without having any religious belief whatsoever. In short, natural law is grounded on reason, not faith.

Is there not some distance between natural law theory and a detailed practical ethics? How can a medical practitioner use it to address thorny ethical issues in clinical practice?

There is always a distance between theory and practice, whichever ethical theory one adopts. But, partly because of the centuries-long history of the natural law tradition, much of the intellectual heavy lifting about its application to practical situations has already been done. That rich storehouse of reflection has shaped our laws and codes of professional ethics, whether in relation to carrying out research on patients, to treating or withholding treatment, and to killing or not killing.

That is not to say that natural law has figured out definitive answers to all the bioethical questions clinicians face in the contemporary world, but many of these questions are largely old questions in a new form. For example, the question of the moral status of the human embryo in vitro may have seemed utterly novel to many, but natural law theorists have been reflecting on the moral status of human embryos in vivo for centuries. Again, the question whether to withhold or withdraw tube-feeding from a patient in PVS may, again, seem completely new and to require us to invent new ethical principles, but to natural law thinkers the answer lies in applying established ethical criteria which ask whether tube-feeding is a medical treatment and, if so, whether it is disproportionate as being either futile or too burdensome. This is not to suggest that the answers to such questions are easy, and will always attract consensus (even among natural law theorists) but it is to say that even challenging, contemporary bioethical questions can be resolved by the intelligent application of well-established principles.

In any event, we should not forget that most clinicians, most of the time, are not confronted with complex, thorny bioethical issues. Most bioethical issues they face in everyday practice are fairly easily resolved by the application of established principles and codes of bioethics, such as those requiring informed consent and respect for confidentiality. And those principles and codes often reflect, to a greater or a lesser extent, natural law thinking, which requires respect for the basic rights and equality-in-dignity of each patient, not least the vulnerable, and that patients never be used as a mere means to the good of others.

What would you say to natural law critics of the ‘new’ natural law theory which has been championed by philosophers like Grisez and Finnis?

Professors Grisez and Finnis (and their collaborators, not least Professor Boyle) have been largely responsible for the exciting renaissance of natural law theory over the past 35 years or so. They would resist the label ‘new’ natural law on the ground that their theory is but a modern restatement of classical natural law theory. Not all natural lawyers would agree with that, but it seems to me that many of the criticisms are based on misunderstandings of the ‘new’ natural law project. This is one reason I co-edited (with Professor Robert P George of Princeton) a Festschrift in honour of John Finnis, (Reason, Morality and Law: The Philosophy of John Finnis) which was published by Oxford University Press in 2013, to allow both supporters and critics of his new classical theory to engage with him, and him with them.

In any event, college students and health care professionals interested in learning the basics of natural law bioethics may well find disagreements about whether and if so how the new classical theory of natural law differs from the old rather abstract and abstruse, and I would encourage them to start with some of the more introductory books and articles on natural law bioethics, written by scholars including Christopher Kaczor, Christopher Tollefsen, David Oderberg, Luke Gormally, David Jones, Helen Watt and, of course, the late Alfonso Gómez-Lobo.

This article is published by John Keown and Xavier Symons and BioEdge under a Creative Commons licence.